Is restricting services at secular hospitals OK?
Religious freedom vs. impact on public health
The debate over access to reproductive health services, particularly abortion, has seen many battles in the legal and legislative arenas. But the growing number of secular hospitals merging with religiously affiliated health systems may end up making those debates moot.
In many cases, when a hospital decides for financial reasons to merge with a church-run hospital, the administration of the first hospital finds that it must agree to limit or end services the church disapproves. In some communities, that has resulted in a loss of reproductive health services to an entire city or county.
Lorain (OH) Community Hospital, for example, stopped providing elective sterilizations and other reproductive health services after merging with St. Joseph Regional Hospital, according to information published by Mergerwatch, a project of the nonprofit advocacy group Family Planning Advocates of New York State. Merger watch monitors health care mergers and acquisitions nationwide for their impact on access to reproductive health care.
According to the Reproductive Freedom Project of the American Civil Liberties Union, Nashville, TN-based Columbia/HCA Healthcare Corporation initially agreed to stop providing abortion services at 18 of its Georgia hospitals and would prohibit physicians who worked at the hospitals from providing abortion services if a joint venture between HCA and Georgia Baptist Medical Center were approved. Although the proposed venture later dissolved, family planning advocates were concerned that such a large health system would readily agree to halt such services in order to merge with a church-owned institution.
"Not only do these agreements signal a loss of reproductive health services to large segments of the population in what may be their health plan hospital or closest hospital, it also means that training is affected, because residents who train for obstetrics and gynecology in these settings are graduating with what many consider to be an insufficient education in women’s health care," says Catherine Weiss, director of the ACLU’s Reproductive Freedom Project.
The project has funded legal challenges to a number of secular/sectarian hospital mergers on antitrust grounds, as well as challenges that question the legality of religiously affiliated hospitals accepting federal funds in the form of Medicare and Medicaid reimbursement and refusing to provide legal medical services.
However, many states now have "conscience clauses," laws permitting individuals, health care facilities, and, in some instances, health plans to withhold services to which they have religious, ethical, or moral objection.
Weiss says she believes that to be an inappropriate extension of religious exemption from civil duties. "In addition to examining the public health issues in terms of what services should be available, the ACLU is also looking at this in terms of what is an appropriate religious freedom claim and [what is] an inappropriate and unjustified religious freedom claim."
Catholic health care plays leading role
Although access to certain reproductive health services — mainly abortion, sterilization, dispensing of contraception, and infertility treatments — are restricted at many hospitals owned by religious organizations, the focus of many family planning and choice advocates’ opposition is on Catholic-owned and operated health systems.
According to statistics from the New York City-based Alan Guttmacher Institute,1 a nonprofit reproductive issues research organization, Catholic hospitals comprise the largest single group of religiously sponsored hospitals and health systems in the United States. In 1996, five of the nation’s 10 largest health care systems were Catholic.
Catholic hospitals are governed by a set of rules established by the National Conference of Bishops. These rules, known as the Ethical and Religious Directives for Catholic Health Care Providers, set out the church’s position on providing health care. Among the directives are items prohibiting the performance of abortion and restricting the provision of contraception, family planning, sterilization procedures, and fertility treatments.
The Washington, DC-based Catholics for a Free Choice, a nonprofit pro-choice advocacy organization, estimates that of the 127 Catholic hospital mergers since 1990, half of the secular merging organizations agreed to adopt the Catholic hospital’s policy and abide by the Directives.
Catholic health care officials emphasize that their position on abortion and other reproductive health services is rooted in their basic mission of preserving life and holding all life as equal in worth.
"Reproductive service issues are very important issues to our community and to our society as a whole, but they are not the most important issues in these joint ventures," contends the Rev. Dennis Brodeur, PhD, senior vice president of stewardship for the St. Louis-based Sisters of St. Mary (SSM) Health Care System. SSM is a Catholic system that owns, operates, and manages 19 acute care hospitals and participates in integrated health systems in Missouri, Illinois, Wisconsin, Oklahoma, Georgia, and South Carolina.
"Reproductive services get so much media attention, when the long-standing constant availability of a variety of services to the entire community is a much larger issue," says Brodeur.
He emphasizes that the same values that cause the Catholic health system to oppose abortion and physician-assisted suicide also drive its commitment to ensuring universal access to health care, including an emphasis on providing health care to the poor and maintaining health facilities in rural, underserved areas.
"Those are the things that are most at-risk when health care systems merge," Brodeur explains.
He also disputes the widely disseminated notion that Catholic systems force their secular partners to completely abandon the reproductive health services they previously offered.
"For us, I think the abortion piece they would definitely have to agree to [stop providing]," he says. "On the contraceptive or other reproductive services, if we are working with an other-than-Catholic facility, we have generally not had restrictions on all of those reproductive services. Our intention is not to get those people to all of a sudden to be Catholic or join the Roman Catholic Church."
However, Brodeur sees economics forcing hospitals, both religious and otherwise, to consider which services they should offer that will benefit the most people in the communities they serve.
"We do make decisions on where the focus should be, what the goals should be," he says. "We serve a lot of rural areas. We are probably not going to spend the money to offer in vitro fertilization at a rural health center that has trouble funding a legitimate CAT scan. We are unlikely to put in a normally noncovered service at $25,000, that most of these people in rural America cannot afford anyway."
He adds that, for many of the communities in which Catholic hospitals operate, access to abortion services already was limited by factors separate from religion.
"If you come to Missouri or southern Illinois for a reproductive program — in Illinois, for example, from Mt. Vernon south you’re going to have to go to a program associated with the University of Illinois at Carbondale, its medical school, or you’re going to have to go to Spring field and one of its clinics there. That is not a religious or Catholic thing. It is a matter of having a bunch of 3,000-person towns where no one is going to open a reproductive services clinic," he explains.
Legal and ethical questions remain
Weiss of the Reproductive Freedom Project disputes the contention that Catholic hospitals respond to the community mores rather than force their ideals upon the community through economics. For example, most abortions, both she and Brodeur acknowledge, are performed outside the hospital at freestanding health clinics.
"That is true. But, the problem is that in most places, by regulation or by policy, freestanding clinics that perform surgery must affiliate with a hospital," Weiss explains.
"If a patient goes into crisis during the operation, they have someplace to take her immediately where they know she will be taken care of. The Catholic system does not affiliate with freestanding abortion clinics because that is prohibited in the directives.
"If the Catholic hospital and its affiliates are the only hospitals in an area, you cannot open a freestanding abortion clinic. That is why it affects the availability of services in whole regions. When you compound this with the lack of medical education in these services, it starts to present a public health problem of much greater magnitude than it originally looked like, right?" she says.
The ACLU recently sought to challenge the "conscience" claims of religiously affiliated hospitals, because it feels their religious exemption has been applied inappropriately, Weiss adds. "Religious institutions exist in a special place in American civil law, and they are freed and ought to be freed of the requirements of civil law in many of their activities. However, what we have traditionally considered to be an exempt organization was an institution that was a pervasively sectarian organization engaged in religious practices. The institution exists mainly to inculcate religious tenants.
"What we [the ACLU] will not recognize is an institution that asserts an exception and then wants to impose it on everyone else at that institution, regardless of their faith, and that institution is not a pervasively sectarian institution designed for a religious function," Weiss continues.
That category includes nearly every sectarian hospital in the country, she adds. "They all receive public money in the form of Medicare and Medicaid, and they all employ and serve diverse populations; they are not limited to serving and employing people of their own faith.
"Why is it in conformity with either ethics or law to allow that institution to require all of its providers and patients to conform with its religious views?" questions Weiss. "That is out of step with our notions about what conscience is about and that it is exercised at an individual level."
Reference
1. Alan Guttmacher Institute. Emerging Issues in Repro ductive Health: A Briefing Series for Journalists. Fact Sheet: Affiliations Between Religious and Secular Health Care Facilities. New York City; Jan. 29, 1998.
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